AD/HD, Stimulants, and Substance Abuse

Media stories about stimulant medications for AD/HD are often misleading. Learn what research tells us about AD/HD medications and the risk of substance abuse in children and teens.

You've seen the headlines:

Ritalin^® Gains Popularity as Party Drug

Students Sell Prescription "Speed" to Classmates

If you're a parent whose child takes prescription stimulant medication for Attention-Deficit/Hyperactivity Disorder (AD/HD) - or you are considering medication for your child - you probably find such news alarming - and confusing. Put your newspaper aside. Turn off the TV news. Let's look at what recent research tells us and get a clear perspective on the benefits and risks of kids taking stimulants to manage AD/HD.

AD/HD and Substance Abuse

In a 1998 report, the National Institutes of Health summarized the results of several studies that showed adults with AD/HD reported higher rates of substance abuse than the general population. The risk of a person developing a substance abuse problem (alcohol and/or drug addiction) during his lifetime is twice as high (52%) for those with AD/HD than for those without the condition (27%).

Why are people with AD/HD at greater risk? To understand this, consider what people with AD/HD must often cope with as they grow up, especially if their condition isn't managed well:

• Poor school performance, due to inattention
• Behavior problems, often related to poor impulse control
• Impaired social skills

Years of struggling with these challenges can severely erode a youngster's self-esteem. Poor self-esteem, coupled with the need for immediate gratification many kids with AD/HD feel, can lead them to seek refuge by "self-medicating" their problems with alcohol or inappropriate use of drugs, including prescription stimulants or illicit drugs.

This challenge is compounded by the fact that an estimated 40% to 60% of kids with AD/HD suffer from at least one other psychiatric disorder. Research suggests, for example, that conditions such as conduct disorder and bipolar disorder increase the risk of substance abuse in teens with AD/HD.^1,2

Other factors that increase the odds that a child with AD/HD will develop a substance use disorder (SUD) include:

• a family history of drug abuse
• exposure to active drug abuse in one's household
• cigarette smoking by the teen³

Managing AD/HD: Stimulant Use versus Abuse

One key to preventing substance abuse is for AD/HD to be diagnosed early and managed effectively. Proper management of AD/HD usually includes behavior modification, appropriate accommodations at home and school, and, for the majority of kids with AD/HD, taking medication prescribed by a physician.

Unlike most medications prescribed for AD/HD, stimulants have a long track record and are approved by the Food and Drug Administration (FDA) for treating the disorder. It's critical for parents, teachers, and the doctor to monitor a child's response to medication on a regular basis. The dosage may need adjustment based on the child's reaction, physical growth, hormonal changes, and side effects.

The nagging concern that therapeutic stimulant use may lead to future substance abuse has prompted researchers to study youth with AD/HD over time. So far, the research results are encouraging. Several recent studies have revealed the role of responsible medication management of AD/HD in reducing the risk of developing substance abuse problems.

Here are the findings of two of those studies:

• A study at Massachusetts General Hospital in Boston concluded children who received stimulant medication for AD/HD were at an 84% lower risk of substance abuse compared to kids with AD/HD who went without medication.⁴ These results mirror previous findings from studies on adults.
• A meta-analysis conducted by Dr. Timothy Wilens, associate professor of psychiatry at Harvard Medical School, and colleagues showed that children who took stimulant medication as part of their treatment for AD/HD were only half as likely to develop a substance abuse disorder in adolescence or adulthood as were peers with AD/HD not treated with psychostimulants.^5,6

Results like these should help parents breathe easier. Yet, it's critical that parents continue to ensure appropriate overall management of their children's AD/HD, including monitoring the child's well-being by working with teachers, doctors, and the kids themselves.

 "Safer" Stimulants

At this time, the vast majority of kids who take medication for AD/HD take stimulants. Vyvanse^®, one of the newest stimulant medications, has been shown to have a lower abuse potential than other forms of amphetamine. Recent research also suggests long-acting forms of stimulant medication are less likely to be abused than are shorter-acting forms.^7,8

Non-stimulant Medications to Manage AD/HD

Several non-stimulant medications appear to be effective for managing AD/HD. Strattera^®is one such medication. It acts much like a stimulant but is not a controlled substance. Strattera may be an appropriate first-line medication for children who have AD/HD and also have a family history of substance abuse. Two other groups of medications that are effective in managing AD/HD in some children are antidepressants and antihyptertensives.

Ultimately, it's up to you and your child's doctor to decide if medication - and which type of medication - is the right choice for managing your child's AD/HD. As your child matures, he should be included in medication decisions.

Teaching Your Child to be Responsible with Medication

When your child is in elementary school

• It's your responsibility to dispense his medication as prescribed. You may want to develop a system of coordinating and documenting your child's doses with any other adult caregivers in your home. This will help you avoid missing or repeating doses.
• If your child must take a dose of medication (e.g., a short-acting stimulant) during the school day, arrange for a school staff member to give him the medication at the appropriate time. Give the school a supply of medication in the prescription bottle, clearly labeled with your child's name, doctor's name, and current dosing information (time of day and dosage strength/number of pills)
• It's never too early to start teaching your child why proper dosage and timing is important - and that taking too much or too little medication isn't desirable.
• Be sure your child understands that his doctor has prescribed the medication only for him and that sharing it withy anyone else is unsafe.

When your child is in middle school and high school

• Gradually give your child more responsibility for taking his medication on time, and in the proper dose. This transfer of responsibility will depend largely on his level of maturity and reliability.
• If he takes a long-acting formula once a day, at home, you can maintain fairly good control over his medication. If, however, he needs to take any of his daily doses (e.g., a short-acting stimulant) - but he's too self conscious or too independent to make a special trip to the school office. - ask school administrators if their policy allows your child to carry his own medication. If the school allows this, be sure to dole out only the dose(s) your child will need during the day. Have him carry his medication in a prescription bottle (as described above).
• Talk openly with your child about the fact that kids sometimes misuse their own prescription stimulants (e.g., to get high, or stay extra-alert while cramming for a test). Explain why this isn't safe and can, if done often, lead to later substance abuse problems.
• Warn your child that some teenagers try to gain favor with kids who carry prescription stimulants, as a means for getting access to such drugs to "get high." A child with AD/HD who is socially awkward may be flattered by the attention and comply to gain acceptance. On the other hand, a teen with AD/HD who tends to disobey authority and/or acts on impulse might be tempted to share or even sell his medication to others. Either way, the consequences for your child can be dire. Help him understand that his safety and self-esteem are far more important than pleasing individuals who wish to take advantage of him.

As your teen leaves home to live on his own

As your teen prepares to move into an apartment or a college dorm, make sure he:

• knows how (and where) to have his prescriptions refilled. If he takes a stimulant, remind him that he may need to visit his doctor each time he needs authorization for the next refill; this adds time to the refill process.
• has a system for storing and taking his medication on schedule.
• understands how the lack of adult supervision will make it critical for him to safeguard and safely take his medication - and to stand up against peer pressure to misuse or share his medication.

Stay Tuned

Scientific research into the relationship between AD/HD, stimulant use, and substance use disorders is ongoing. The development of non-stimulant drugs to treat AD/HD will likely continue. As a parent, you'd be wise to stay abreast of news on both fronts.

Medication Warnings

Warnings about possible side effects of prescription medications are updated frequently. To stay abreast of recent warnings that may have been issued on your child's medication, visit the U.S. Food and Drug Administration Consumer Education/Information website, and ask your pharmacist for an update each time you refill the prescription.

AD/HD by Other Names and Acronyms

While Attention-Deficit/Hyperactivity Disorder (AD/HD) is the official term and acronym used by today's mental health care professionals, it is sometimes referred to by other names and abbreviations. For example, it is sometimes called:

ADHD (without the "slash" in the middle)

Attention Deficit Disorder (ADD)

Attention Disorder